Different cucurbitacin derivatives have been compared for the gamma globin induction potential. Cucurbitacin D turned out to be the most potential inducer among the derivatives had been tested. Later I had screened more herbs for the gamma globin induction activities. One of the herbs showed a higher activity than Fructus Trichosanthis, which could be the potential candidate to isolate more potent inducer. In the toxicity study, cucurbitacin D only have a mild toxic effect on the normal cell lines and transgenic mice. Finally, the efficacy of cucurbitacin D was tested on a sickle cell anemia mouse model and demonstrated a significant induction of fetal haemoglobin production. Cucurbitacin D may be a potential drug candidate for treating beta globinopathies. / Thalassemia is a global disease. It was report in 2001 that there were 270 million people who carried the severe disease. Most of the cases were found in Africa and south-east Asia. China has a high incidence rate of 0.66% in 2001. In the past, the treatments of the disease were blood transfusion and bone marrow transplantation. However, many defects in such kinds of treatments were reported. The balance of relieving the syndrome of the disease and the adverse effects of the drugs was the consideration to the physician. The drug, hydroxyurea, can activate the gamma globin gene and produce hemoglobin F to replace the beta globin as an oxygen transporter is considered as an better treatment to ameliorate the syndrome. Safety and effectiveness in the long-term treatment using hydroxyurea are questionable. Cucurbatacin D purified from a Chinese herb demonstrates 2000 folds more potent than hydroxyurea. It can activate the gamma globin gene and produce hemoglobin F shown in ELISA and confocal microscopy. The fundamental work for drug development is carrying out through this project. In this project the biological property and toxicity were studied. / Liu, Shuk Ming. / Adviser: M.C. Tung. / Source: Dissertation Abstracts International, Volume: 73-02, Section: B, page: . / Thesis (Ph.D.)--Chinese University of Hong Kong, 2010. / Includes bibliographical references (leaves 245-270). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [201-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese.

by Li Chi-kong. / "September 2002." / Thesis (M.D.)--Chinese University of Hong Kong, 2002. / Includes bibliographical references (p. 223-251). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. Ann Arbor, MI : ProQuest Information and Learning Company, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Mode of access: World Wide Web.

published_or_final_version / Pathology / Master / Master of Medical Sciences

published_or_final_version / abstract / toc / Medicine / Master / Doctor of Medicine

Talassemias são as mais comuns desordens monogenéticas em humanos; são caracterizadas pela presença de anemia microcíticas e hipocrômicas que resultam da redução ou ausência na síntese de uma ou mais cadeias globínicas. No Brasil a beta-talassemia tem importante significado clínico e sua ocorrência pode ser explicada como conseqüência da grande mistura étnica. A beta-talassemia é extremamente heterogênea e mais de 200 mutações têm sido descritas causando diferentes graus de anemia. Essas mutações são regionalmente específicas e cada país possui seu grupo de alterações característico. No estado homozigoto são classificadas clinicamente como major e no estado heterozigoto como intermédia e minor. Os pacientes com talassemia intermédia podem não apresentar sintomas clínicos, mas constatam-se características laboratoriais específicas. A avaliação dos índices hematológicos, dosagens dos parâmetros bioquímicos e dos valores das hemoglobinas fetal e HbA2 em combinação com o entendimento das possíveis interações gênicas são os procedimentos recomendados para o diagnóstico laboratorial. O objetivo deste estudo foi determinar a presença de mutações em pacientes que utilizam a Divisão de Laboratório Central do Hospital das Clínicas da Faculdade de Medicina da Universidade São Paulo (DLC-HC-FMUSP) e que apresentavam perfil laboratorial sugestivo para beta-talassemia. Estudou-se a região do gene da globina em onde estão descritas as mutações mais freqüentes para nosso meio através da técnica de PCR, e posterior seqüenciamento para identificação das mutações. As mutações observadas na população avaliada (N=40), em ordem crescente de freqüência foram: Codon 39 (CT), IVS-I-110 (GA), IVS-I-1(GA), IVS-I-5 (GC), IVS-I-6 (TC), IVS-I-Exon-II (GA), Exon-II-IVS-II (GA), Stop Cd 6 (GT), Stop Cd15 (GA), Del C Cd 44 e 5UTR+20. Os primeiros quatro genótipos representaram 82,5% das mutações observadas neste trabalho. O uso combinado dos índices hematimétricos, parâmetros bioquímicos e avaliação das características morfológicas das hemácias demonstraram eficiência no rastreamento de pacientes portadores de beta-talassemia, assintomáticos A técnica do PCR e posterior processo de seqüenciamento demonstraram elevada eficiência na determinação das alterações moleculares no grupo de pacientes avaliados. / Thalassemias are the most common monogenic disorders in humans; are characterized by hypochromic and microcytic anemia arising from the reduction or absence in the synthesis of one or more chains globínicas. In Brazil, beta-thalassemia has important clinical significance and its occurrence can be explained as a result of the large ethnic mix. The beta-thalassemia is extremely heterogeneous and more than 200 mutations have been described causing varying degrees of anemia, these mutations are regionally specific and each country has its characteristic group of amendments. In the homozygous state are clinically classified as major and the heterozygous state as intermediate and minor. Patients with thalassemia can not present interim clinical symptoms, but have characteristics specific laboratory. The evaluation of hematologic indices, strengths and biochemical parameters of fetal hemoglobin and HbA2 values in combination with an understanding of possible interactions genes, are the recommended procedures for laboratory diagnosis. The purpose of this study was to determine the presence of mutations in patients who use the Division of Central Laboratory of the Hospital of the Faculty of Medicine of the University Sao Paulo (DLC-HCFMUSP) who presented suggestive profile laboratory for beta-thalassemia. It was studied the region of the gene of beta globin where they are frequently described the changes to our region through the PCR technique, and subsequent sequencing to identify the mutations. Of the 40 patients evaluated were found the following changes: Codon 39 (CT), IVS-I-110 (GA), IVS-I-1 (GA), IVS-I-5 (GC), IVS-I-6 (TC), IVS-I-Exon-II (GA), Exon-II-IVS-II (GA), Stop Cd 6 (GT), Stop Cd15 (G A), Del Cd 44 and 5UTR+20. The first four genotypes accounted for 82.5% of mutations observed in this study. The combined use of hematologic indices, biochemical parameters and evaluation of morphological characteristics of red blood cells demonstrated efficiency in the tracking of patients with beta- thalassemia, asymptomatic. The technique of PCR and subsequent process of sequencing demonstrated high efficiency in determining the molecular changes in the group of patients evaluated.

Γενετικές παραλλαγές σε γονιδιακούς τόπους που βρίσκονται εντός (cis) αλλά και εκτός (trans) του συμπλέγματος των ανθρώπινων β-σφαιρινικών γονιδίων έχει δειχθεί πως συσχετίζονται σημαντικά με τα επίπεδα της εμβρυϊκής αιμοσφαιρίνης (HbF). Ένα από τα γονίδια αυτά είναι το γονίδιο MAP3K5 (ή ASK1), το οποίο είναι μέλος της οδού της MAP κινάσης, ενεργοποιείται από διάφορες παθολογικές καταστάσεις και από προ-φλεγμονώδεις κυτοκίνες, συμβάλλοντας στην κυτταρική απόπτωση. Πρόσφατα αποτελέσματα από το εργαστήριό μας έδειξαν ότι η παρουσία του σπάνιου αλληλομόρφου C σε μονονουκλεοτιδικούς πολυμορφισμούς (SNP) του συγκεκριμένου γονιδίου, και συγκεκριμένα στους rs9376230 και rs9483947, συσχετίζεται με μειωμένα επίπεδα της εμβρυϊκής αιμοσφαιρίνης (HbF) (Tafrali et al., 2013). Για το λόγο αυτό, υποθέσαμε ότι οι πολυμορφισμοί αυτοί συνδέονται με πιθανές αλλαγές σε ρυθμιστικές περιοχές του γονιδίου ΜΑΡ3Κ5 οι οποίες τροποποιούν τα επίπεδα έκφρασής του. Έτσι, ερευνήσαμε τον υποκινητή του γονιδίου ΜΑΡ3Κ5 ως προς τη συχνότητα παρουσίας τεσσάρων ή πέντε αντιγράφων της μικροδορυφορικής αλληλουχίας 5’ – GCGCG – 3’ (θέση -51 έως -27 από τη θέση έναρξης της μεταγραφής). Με την προσέγγιση αυτή θελήσαμε να εξακριβώσουμε εάν οι μικροδορυφορικές αυτές αλληλουχίες συνδέονται με τους μονονουκλεοτιδικούς πολυμορφισμούς και, κατά συνέπεια, με τα επίπεδα της HbF σε ασθενείς με ενδιάμεση ή μείζονα β-μεσογειακή αναιμία και σε μη-θαλασσαιμικά άτομα. Για τον σκοπό αυτό, χρησιμοποιήθηκαν 11 ασθενείς με ενδιάμεση β-μεσογειακή αναιμία, 15 ασθενείς με μείζονα β-μεσογειακή αναιμία και 60 μη-θαλασσαιμικά άτομα ελληνικής καταγωγής. Ο προσδιορισμός του γονότυπου πραγματοποιήθηκε με εκλεκτική ενίσχυση του τμήματος του υποκινητή του γονιδίου ΜΑΡ3Κ5, μεταξύ των θέσεων -273 έως και +79, και στη συνέχεια, είτε με αλληλούχιση σε αυτοματοποιημένο αναλυτή ή με ανάλυση ετεροδιμερών. Η ανάλυση έδειξε ότι υπάρχει σχεδόν απόλυτη σύνδεση των σπάνιων αλληλομόρφων C τόσο για τον rs9376230 όσο και για τον rs9483947 με τη μικροδορυφορική αλληλουχία των πέντε επαναλήψεων, σχηματίζοντας έναν απλότυπο. O συγκεκριμένος απλότυπος συσχετίζεται με χαμηλά επίπεδα της HbF και το φαινότυπο της βαριάς β-μεσογειακής αναιμίας, αφού σε ασθενείς με μείζονα β-μεσογειακή αναιμία εντοπίζεται με συχνότητα 60% και αποκλίνει στατιστικώς σημαντικά από τις αντίστοιχες συχνότητες σε ασθενείς με ενδιάμεση β-μεσογειακή αναιμία (p=0,04) και σε μη-θαλασσαιμικά άτομα (p=0,003). Τα αποτελέσματα αυτά δείχνουν ότι οι πολυμορφισμοί rs9376230 και rs9483947 συνδέονται με τη μικροδορυφορική αλληλουχία του υποκινητή, η οποία έχει πιθανό λειτουργικό ρόλο στα επίπεδα έκφρασης του γονιδίου ΜΑΡ3Κ5. / Genetic variations in loci that are in cis or trans of the human beta-globin gene cluster are shown to correlate significantly with the levels of fetal hemoglobin (HbF). One of these genes is MAP3K5 (or ASK1), a member of the MAPK pathway, which is activated by various stresses and pro-inflammatory cytokines that contribute to cellular apoptosis. Recent results from our laboratory have shown that the presence of the rare C allele in two intronic SNPs of MAP3K5, namely rs9376230 and rs9483947, is associated with reduced levels of fetal hemoglobin (HbF) (Tafrali et al., 2013). For this reason, we assumed that these polymorphisms may be associated with changes in the regulatory regions of MAP3K5 which could modify its expression levels. Thus, we investigated the frequency of a microsatellite marker at the proximal promoter region of MAP3K5, regarding the presence of four or five repeats of a 5-bp short tandem repeat (STR), am y 5’ – GCGCG – 3’ (positio -51 to -27 from transcription start site). With this approach, we wanted to ascertain whether this STR is associated with the previously studied SNPs (Tafrali et al., 2013) and consequently with th v s o bF i β-thalassemia intermediate or major patients compared to non-thalassemic individuals. For this purpose, we analyzed the DNA samples from 11 β-tha ass mia i t rm ia a 15 β-thalassemia major patients, as well as 60 non-thalassemic controls of Western Greek origin. Genotyping was performed by selectively amplifying a MAP3K5 gene promoter fragment between positions -273 to +79, followed by either sequencing or heteroduplex analysis. The analysis showed that there is an almost perfect correlation of the rare C allele for rs9376230 and the rare C allele for rs9483947 with the five STR repeats, forming a haplotype associated with low levels of HbF and with the phenotype of severe b-thalassemia. This haplotype is detected with a r qu cy o 60% i β-thalassemia major patients and it statistica y sig i ica t y viat s rom th corr spo i g r qu ci s i β-thalassemia intermedia patients (p = 0.04) and in non-thalassemic individuals (p = 0.003). These results indicate that the polymorphisms rs9376230 and rs9483947 are in linkage with the promoter STR polymorphism, which may have a functional role in MAP3K5 gene expression.

published_or_final_version / Social Work / Master / Master of Social Work

published_or_final_version / Obstetrics and Gynaecology / Master / Master of Philosophy

Osteopenia and/or Osteoporosis (OOS) is becoming an increasingly prevalent chronic disease among Beta Thalassemia Major (BTM) patients, especially now that life expectancy in these patients has considerably improved through regular blood transfusions and iron chelation therapy. With several, complex genetic and acquired factors involved in its pathogenesis, coupled with the heterogeneity in the clinical response of BTM patients to different pharmacological agents, OOS has proven to be particularly difficult to treat. The great majority of treatment options currently available are not curative, but instead are aimed towards managing the symptoms and progression of the disease in patients. General preventative measures, such as iron chelation therapy and hormonal replacement therapy (HRT), are instrumental aspects of the treatment plan; however, the incredible complexity of OOS necessitates an individualized, multidisciplinary approach to management, with a principal therapy that is safe and effective in patients, and that is accompanied by these other supportive measures. This review, through a comprehensive analysis of current literature, includes data from randomized, placebo-controlled trials, double blind and observational clinical studies, and suggests optimal therapeutic interventions for first-line management of OOS. It also addresses treatment options for BTM patients in whom resistance to the recommended first-line therapy develops, or who display secondary endocrine conditions contributing to OOS. In addition to providing a current synopsis of OOS management and the potential of emerging treatment options, this analysis highlights some of the limitations of traditional therapies. In this way, the paper effectively illustrates the current status of TM-induced OOS; it describes what is or isn’t working, as well as underscores the diagnostic and therapeutic challenges continually faced by patients, researchers and clinicians.

A ?-talassemia, uma hemoglobinopatia, é caracterizada como um distúrbio hereditário monogênico onde a síntese das cadeias globínicas ? está alterada. Devido desiquilíbrio na relação entre as cadeias ? e ? produzidas, observa-se um excesso de cadeias ? livres, determinante da fisiopatologia da doença. As manifestações observadas são eritropoese ineficaz, hemólise extramedular, anemia, expansão medular, esplenomegalia, deformidades ósseas e acúmulo de ferro. Clinicamente classifica-se como ?-talassemia major (BTM) a forma mais grave da doença, devido à ausência de cadeias ? (?0) ou redução acentuada (?+) acarretando em dependência de transfusões sanguíneas periódicas, para sobrevivência. O traço ?-talassêmico (BTT) antes vistos como assintomáticos, também apresentam alterações, inclusive acúmulo de ferro e eritropoese ineficaz, mas não são dependentes de transfusão e tampouco passam por acompanhamento médico. Extremamente heterogênea, apresenta diversos fenótipos e mais de 300 alterações moleculares causadoras de ?-talassemia já foram descritas em todo mundo. O objetivo deste estudo foi identificar as mutações de ?-talassemia em Ribeirão Preto-SP e procurar associar tais alterações à avaliação hematológica e do status férrico, na tentativa de estabelecer uma relação genótipo-fenótipo. Para tanto, 27 BTM, 23 BTT e 28 controles foram recrutados no Ambulatório de Hemoglobinopatias, do HC/FMRP-USP de Ribeirão Preto. Por meio de PCR-Alelo Específico, pesquisamos as quatro mutações mais comuns no Brasil: CD39 (CAG->TAG), IVS1-110 (G->A), IVS1-6 (T->C) e IVS1-1 (G ->A). A distribuição foi 64% CD39, 26% IVS1-110 e 4% IVS1-6. A análise de covariância e comparação múltiplas, entre os grupos formados e o controle, revelou alterações hematológicas e no status férrico. Os pacientes BTM com a mutação CD39, em sua forma heterozigota ou homozigota, e heterozigotos para a IVS1-110, revelaram anemia grave e intensa sobrecarga de ferro. Os BTT heterozigotos para CD39 demonstraram comprometimento do metabolismo ferro e/ou eritropoese. A adoção de medidas paliativas e de monitoramento aos BTT faz-se necessária, uma vez que, alterações apresentadas associam-se a desordens graves, mas quando não negligenciadas podem ser facilmente prevenidas. A metodologia adotada demonstrou-se eficaz para a pesquisa das mutações estudadas. Embora tenhamos conseguido observar uma relação genótipo-fenótipo, um estudo multicêntrico da população brasileira proporcionará a identificação de mais relações, principalmente nos fenótipos menos prevalentes em nossa região, contribuindo para a compreensão da heterogeneidade da ?-talassemia. / The ?-thalassemia, one haemoglobinopathies, is characterized as a monogenic hereditary disorder where the synthesis of ? globin chains is modified. Due to imbalance in the relationship between production of ? and ? chains, there is an excess of free ? chain that determines the pathophysiology of the disease. Manifestations observed are ineffective erythropoiesis, extra medullary hemolysis, anemia, bone marrow expansion, splenomegaly, bone deformities and iron accumulation. Clinically is classified as ?-thalassemia major (BTM), the most severe form of the disease, as a result of the absence of ? chains (?0) or very large reduction of these (?+) resulting in dependence on regular blood transfusions to survive. The ?-thalassemia trait (BTT) before seen as asymptomatic, also show changes, including iron accumulation and ineffective erythropoiesis, despite of that they aren\'t dependent on transfusion nor undergo medical care. It is extremely heterogeneous, presents several phenotypes and more than 300 molecular changes that causing ?-thalassemia have been described worldwide. The purpose of this study was to identify ?-thalassemia mutations in Ribeirao Preto-Brazil and to explore changes in hematological evaluation and iron status in an attempt to establish a genotype-phenotype relationship. Therefore, a group of 27 BTM, 23 BTT and 28 controls were recruited from the outpatient clinic of hemoglobinopathies, from The Clinical Hospital of Medical School of Ribeirao Preto (HC / FMRP-USP), Brazil. Adopting the technique ARMS (Amplification Refractory Mutation System), we searched for the four most common mutations in Brazil: CD39 (CAG -> TAG), IVS1-110 (G -> A), IVS1-6 (T -> C) and IVS1-1 (G -> A). The distribution was 64% presents CD39 mutation, followed by IVS1-110 e IVS1-6, with 26% and 4% respectively. Covariance Analysis and multiple comparison between the studies groups and control, showed differences in hematological parameters and in iron status either. The BTM heterozygous or homozygous for CD39 mutation and heterozygous for IVS1-110 revealed severe anemia and iron overload. The BTT heterozygous for CD39 showed impairment of iron metabolism and / or erythropoiesis. It is necessary the monitorization of the BTT patients is necessary, since changes presented by them are associated with serious disorders, the adoption of mitigation measures which when are not neglected can be easily prevented. The methodology proved to be effective for the investigation of mutations studied. While we were able to observe a genotype-phenotype relationship, a multicenter study of the Brazilian population will provide the identification of more relations, especially in less prevalent phenotypes in our region, contributing to the understanding of the heterogeneity of ?-thalassemia.